Inflammation Targets Specific Organs for Cancer in Carriers of BRCA1/2 Pathway Mutations

Inflammation targets specific organs for cancer in carriers of BRCA1/2 pathway mutations

Bernard Friedenson

Department of Biochemistry and Molecular Genetics College of Medicine University Illinois Chicago 900 South Ashland Ave Chicago, IL 60607 Email: [email protected] Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 1

Abstract Women who inherit a defective BRCA1 or BRCA2 gene have risks for breast/ovarian cancer that are so high and apparently so selective that many mutation carriers choose to have the most likely targets for cancer surgically removed. Recent research has focused on better methods of treating such seemingly unavoidable hereditary cancers. Prevention has received much less attention so a positive test result for a cancer gene leaves carriers with very limited options. In order to prevent BRCA1/2 related cancers, it may be important to understand why they seem to occur only in certain characteristic organs. Results here show that mutations in a pathway depending on BRCA1/2 gene products magnify cancer risks from chronic infection and inflammation, making them especially important in selecting the site where hereditary cancer develops. Control- ling chronic infections and inflammation may be a helpful option to prevent or delay cancers in mutation carriers.

Introduction Women who inherit a defective BRCA1 or BRCA2 gene have risks for breast/ovarian cancer that are so high and apparently so selective that many mutation carriers choose to have the most likely targets for cancer surgically removed [1-7]. Recent research has focused on better methods of treating the cancers that seem unavoidable. Prevention has received much less attention so a positive test result for a cancer related mutation leaves carriers with very limited options.

In order to prevent BRCA1/2 related cancers, it may be important to understand why they seem to occur only in certain characteristic organs. Why would cancer just attack breasts and

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 ovaries when every cell with a nucleus contains the same mutation? Functionally, both BRCA genes are general cell requirements because they encode products essential for checkpoint controls and for DNA repairs. How does inheritance of a defect in general cell requirements lead to cancers in specific target organs?

Here the possibility is tested that infection and chronic inflammation direct inherited cancers to specific organ targets. Evidence is overwhelming that chronic inflammation underlies many cancers and that some chronic infections can direct cancer to a specific organ. For example, hepatitis viruses target the liver for cancer because the liver has receptors for hepatitis viruses. Hepatitis B and C viruses do not cause cancer unless chronic inflammation follows infection, leading to DNA breaks [8, 9]. Many normal individuals recover and never develop liver cancer. Inherited cancer related mutations are rare, making risks from chronic inflammatory conditions difficult to study. Results from epidemiology were used to approach this problem. Risks for 2

cancers associated with inflammation in a specific organ were statistically combined from eleven published studies of known or likely mutation carriers. The resulting statistical summaries of cancer relative risks included over 25,000 carriers of any testable mutation in DNA damage responses depending on BRCA1 and BRCA2 gene products. The rarity of BRCA1/2 mutations made it necessary to include all testable components in the subroutine that depends on functional BRCA1 and BRCA2 proteins. Figure 1 shows an approximate arrangement of the testable components in a model subroutine within the DNA damage response [10, 11] Strong evidence supports the idea that inactivating a gene encoding any of these components causes genomic instability and increases cancer risks. All the components in the model participate in DNA damage responses that can be induced by reactive oxygen products from inflammatory processes. These responses are double strand break repair by homologous recombination, repair of collapsed or stalled DNA replication forks, and prevention of hypersensitivity to DNA cross-linking agents. Cancer genome sequences rarely inactivate more than one gene in the same sub-routine. Fanconi anemia (FA), ataxia-telangiectasia (A-T) and BRCA deficiency are hereditary cancer prone diseases caused by inactivation of one gene in the pathway containing BRCA1/2. In each condition there are increased numbers of chromosome breaks, large rearrangements, and/or regional gains and losses in chromosomes [Fig. 1,12, 13]. Multiple steps in the repair of interstrand cross-links can fail when the FA pathway is compromised. A-T patients have elevated risks for DNA damage in tissues undergoing inflammation [14] and FA patients over-express inflammatory genes and proteins [15]. Cells that are deficient in any one of eight FA core complex proteins are defective in monoubiquitylation of FANCD2 and FANCI. This defect causes chromosome breakages and FA hypersensitivity to DNA cross-linking agents. (See footnote to Fig 1). Here, mutation carriers were found to have strikingly increased risks for cancers connected to known chronic inflammatory infections such as liver cancer, cervical cancer and stomach can-

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 cer. Risks increase hundreds of times in homozygotes and up to several-fold in heterozygotes. For BRCA1/2 related breast and ovarian cancers, cancer prevention data and evidence of immune responses suggest that chronic inflammation helps target these organs. Inflammation also disrupts normal cellular organization and architecture, further favoring cancer. Identifying and controlling chronic infections and inflammation may delay or prevent some hereditary cancers in mutation carriers.

Materials and Methods Identification of studies. Epidemiologic data exists describing effects of mutation of numerous components within the DNA damage response network [16]. In order to reduce bias, explicit procedures [17] were used to systematically identify, appraise, summarize and statistically ag- gregate relevant studies.

Information sources. PubMed and Google Scholar databases were systematically searched 3 3

DNA Double Strand Break

v acti atio in n RAD50 CHEK2 MRE11 ATM Nbs1 BRCA1 Fanconi anemia Chromosome protein J Other inactiva Fanconi Rearrangements, tion Chromosome anemia Regional Gains, proteins Rearrangements, Losses Regional Gains, BRCA2 Losses FANCD1 Homologous recombination “Error-free” DNA repair

Fig 1. Simplified model for a double strand break repair subroutine emphasizing components that have epidemiologic studies measuring risks for multiple cancers beyond breast and ovarian cancer. Inactivation of ATM, Fanconi genes, or BRCA1/2 genes in hereditary conditions causes large chromosomal rearrangements, losses or gains of sections of chromosomes [11-14]. BRCA2 is the same as Fanconi component D1. FA protein J is the same as BRIP1 (BRCA1 interacting protein 1). Mutation of genes encoding any of numerous pathway components produces cancers in an overlapping distri- bution of organs. For example, mutations in NBS1, RAD50, ATM, BRCA1, BRCA2, CHEK2, FANCJ (BRIP1), or FANCN (PALB2) have each been associated with increased breast cancer risks. Not shown are numerous interactions with other proteins and relationships to cell cycle checkpoints (see footnote). The results reported here do not require that the pathway be linear and do not preclude participation by hormones. Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 Footnote Details of this outlined pathway are still emerging but many publications place FA proteins in the DNA damage network including BRCA1 and BRCA2 with activation by ATM and Rad3 related (ATR) kinase [e. g. 74, 75, 11]. Of the 13 FA proteins identified, eight of these, including FANC-A, -B, -C, -E, -F, -G, -L, and -M, form a multi-subunit nuclear FA core complex. In response to replication stress, the FA core complex promotes the monoubiquitylation of the FANCD2-FANCI heterodimer, which triggers their relocalization to sites of replication stress. Cells that are deficient in any one of the eight core complex proteins are defective in monoubiquitylation of FANCD2 and FANCI. The FA core complex acts as the E3 ligase for FANCD2 and FANCI. Any mutations that disrupt ubiquitylation of FANCD2 cause FA chromosome breakages and FA hypersensitivity to DNA cross-linking agents. The other FA factors, FANCD1/BRCA2, FANCJ/BRIP, and FANCN/PALB2, are believed to function downstream of the FA core complex, possibly in the regulation of homologous recombination, also playing essential roles in lesion repair and replication fork recovery [74]. BRCA1 is essential for the formation of nuclear foci, believed to be sites of DNA repair. 4

up to 2010, for original epidemiologic studies of non-breast, non-ovarian cancers vs. any defect in the model pathway in Fig. 1. 1250 articles published in the past 50 years were retrieved and copied to a database to facilitate computer searching and review. Many bibliographies were also reviewed for ad- ditional relevant references that may have been missed. No language restrictions were imposed. Models for inflammation related cancers. From these initial surveys, results were summarized for five cancers that have widely accepted and well-known links to chronic infection as follows. Group 1: liver cancer associated with viral hepatitis such as hepatitis B or C; Groups 2-4: vulvar, cervical, and head and neck cancers, all associated with human papilloma viruses (HPVs); and Group 5: stomach (gastric) cancer associated with helicobacter pylori.

Included research articles analyzed. Comparatively few publications describe cancer histories at sites other than breast or ovary from typed or probable mutation carriers. No studies are available that directly determine the mutation status of every member of a large cohort of non- breast/non-ovarian cancer cases. Therefore, cohorts likely to have a mutation were included based on one or more risk factors for inheriting a mutation in the pathway containing BRCA1/2 proteins: These cohorts had a documented mutation in the family and/or numerous breast or other cancers at age <60. Inherited defects were in FA proteins, BRCA1, BRCA2 or the upstream activator ATM. These cohorts were: patients diagnosed with FA in specialized clinics; all cases of FA from the literature; families having members with positive BRCA1 or BRCA2 test results based in large part on breast cancers in women younger than age 60; women from cancer registries with positive test results or high probabilities of being a BRCA1 or BRCA2 mutation carrier because of strong personal or family histories of breast and ovarian cancers at young ages; male breast cancer patients younger than age 60; cancers at age <60 in blood relatives of A-T patients. Studies containing large numbers of cancers first diagnosed at age 60 or younger lessen the influence of sporadic cancers on effect measures. Coincidentally, risk factors in normal populations

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 for viral infections associated with specific cancers are also higher at younger ages.

Meta-analyses exclusion criteria. Studies of groups having a known probability of carrying a mutation <=20% (3 studies) were excluded. Other exclusion criteria were > 20% of subjects lost due to mortality, illness, refusal to participate, missing information, lost branches of family trees, dropouts, etc. or some other preselection such as ignoring family branches likely to have cancer. Any of these criteria would potentially weight results for cancer survivors or people who never get cancer (7 studies) [18]. For serial studies representing the same population, only the largest study was used (3 studies excluded). Unpublished reports, single case reports and bone marrow transplant recipients were excluded. At least three studies were required for meta-analysis.

Validity and Quality Assessment. A high quality study was considered to have the fol- 5

lowing characteristics. The study had to (1) have sufficient follow-up (1-10 years) (2) include incidence data from >100 individuals for cancers beyond breast and ovarian cancer, (3) have a probability of mutation >20%, assuming a positive family history (4) provide relative risks for cancers beyond breast and ovarian, with confidence intervals (CIs) or sufficient data to allow calculation of RRs and CIs. If exact mutation status was not known, the probability of carrying a BRCA1 or BRCA2 mutation was estimated from other studies of similar populations or with the BRAC analysis risk calcula- tor from Myriad Genetics.

Data extraction. The same standard protocol was followed to extract data from each included study. Data were extracted blindly several times.

Statistical analysis. Included studies differed in the samples chosen as the mutation group and in the details of methods employed. For meta-analyses, the random effects model was used since it allows for measured effects to vary across studies and estimates the inter-study effect variance with a simple non-iterative method [19]. Studies in meta-analyses were weighted according to this model [19]. Random and fixed effects calculations almost always gave identical or very similar results. All reported p values were derived from two-sided statistical tests. No assumptions were made about the risk for a cancer at any individual site unless the study reported this incidence. The reasons for this were as follows. Studies with the largest populations generally reported cancers at the most anatomic sites. Most studies of heterozygotes reported an elevated overall cancer risk especially at early ages, often with some unidentified sites. However every study showed increased risks for multiple identified cancers, with some cancers again occurring at relatively early ages.

Multi-variate and subgroup analyses. The effects of different variables on the statistical results and the robustness of the results were measured by performing meta-analyses using many different combinations of studies and study arms. Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 Heterogeneity testing evaluated whether the effect size in different subgroups (defined biologically or medically) varied significantly from the main effect. The inconsistency of results across studies is summarized in the I² statistic, the percentage of variation across studies due to heterogeneity rather than chance. An I2 value >50% generally indicates significant heterogeneity [20]. Hetero- geneity was also calculated as non-combinability, and by a moment based method. Heterogeneity estimates can have large uncertainty, especially for few trials and were interpreted cautiously. In some cases it was necessary to use cumulative control cancer incidences calculated using the NCI “DevCan” and “SEER” programs. NCI values were verified by comparison to published control values from numerous included references and always agreed well., showing that these control statistics were valid in these populations All statistical results were further tested against independent evidence and theory. There was no statistical evidence of publication bias [21] for final 6

Publications retrieved potentially related to BRCA pathway and dealing with cancers of liver, vulva, cervix, stomach, or head and neck area; n=1250

Publications pertinent to hypothesis that infections/in ammations magnify cancer risks and select site for cancer. Epidemiologic or basic science data; n=35

Publications from basic science Shortlist: Publications providing relative risk data relevant to hypothesis; n=11 or allowing calculations of relative risks relevant to hypothesis that in ammatory infections select liver, vulva, cervix, stomach, or head and neck as target sites for cancer in mutation carriers; n=24

Publications excluded because probability of mutation in the Data summarized as population known to be <20%; n=3 corroborating data Table 3 Publications excluded because other publications with more data superceded them; n=3

Publications excluded because of dropouts or mortality of people likely to have cancers other than breast/ovarian or because of other pre-selection; n=7

Publications used in meta-analyses extracted data shown in Table 1; n=11

FigFig. 2. 2.Flow Flow chart chart showing showing numbers numbers of publications of publications retrieved containing at each relative stage containing risk data for data forcancers cancers of of liver, liver, vulva, vulva, cervix, cervix, stomach stomach or or head and neck area.area. The At numberseach stage of ofpublications retrieval inor each analysis category the numbersare indicated of publications by values for are n inindicated each box. by values for n in each box.

summary estimates (results not shown). Statistical analyses and forest plots were performed with StatsDirect software (StatsDirect, Ltd 2008) and checked with RevMan software. Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 Results Initial search results for 5 cancer associated infection groups. From the database of 1250 articles, a shortlist was identified, consisting of 24 cohort studies containing relative risk data for cancers other than breast and ovarian in mutation carriers. From the shortlist, 11 articles (some including several study arms) met inclusion criteria, passed exclusion tests and met the criteria of quality assessment (Fig. 2). The 11 studies were used in meta-analyses to determine whether BRCA pathway mutations led to elevated risks for five cancers, each with a known links to a chronic inflammatory infection. Table 1 summarizes details of included studies [21-31], giving the characteristics of study participants and listing follow-up periods, cancers found, associated infections, effect measures, and control values.

Chronic inflammatory infections increase risks for cancers in some organs in mutation carriers. Table 1 shows RR data from mutation carriers [21-32] for five organ specific can- 7

T able 1 Details of cohort studies included in initial meta-analyses of known infection related cancers in BRCA pathway mutation carriers.

1289 FA patients from 80 years of literature HBV or HCV liver RR = 574.1 (233.0 - 1414) 37 at median age 13 5/100,000 to age 20 [DevCan] data

356 female surviving FA patients from 80 Survival was about 62% HPV cervix RR=76.61 (23.04-253.1) 3 at mean age 25 11/100,000 to age 25 [DevCan]. FA homo years of literature data for cancers other than zygote / Alter liver. No survival correc- 20/100,000 for cancer of 2003 [21] 799 surviving FA patients from 80 years of tion was applied for liver HPV head and neck RR=162.7 (91.83 - 287.7) 26 at mean age 28 the oral cavity and pharynx literature data cancer. [DevCan].

356 female surviving FA patients from 80 25/1,000,000 to age 30 and HPV vulva RR=1124 (550.3 - 2279) 10 at mean age 27 years of literature data 9/1,000,000 to age 25 [DevCan].

754 North American FA patients followed for HBV or HCV liver RR =477.5 (184.2 - 1236) 39 at median age 13 5/100,000 to age 20 [DevCan] 20 years

228 surviving female N. Amer. FA patients fol- HPV cervix RR=239.2 (92.16 - 615.6) 6 at mean age 25 11/100,000 to age 25 [DevCan]. Survival was about 62% FA homo lowed for 20 years for cancers other than zygote / Kutler liver. No survival correc- 20/100,000 for cancer of the et al [22] 228 surviving female N. Amer FA patients fol- HPV HNSCC (or EBV tion was applied for liver RR=203.4 (110.1 -374.3) 19 at mean age 28 oral cavity and pharynx to age lowed for 20 years nasopharynx) cancer. 35 [DevCan].

228 surviving female N. Amer FA patients fol- 25/1,000,000 to age 30 and HPV vulva RR=1404 (649.0 -3001) 8 at mean age 27 lowed for 20 years 9/1,000,000 to age 25 [DevCan].

145 FA patients: 76 men and 69 women from HBV or HCV liver RR =275.9 (61.89 - 1215) 2 at median age 13 5/100,000 to age 20 [DevCan] up to 40 years of cancer incidence data

69 women from up to 40 years of cancer FA homo HPV cervix RR=422.8 (105.9 -1597) 2 at mean age 25 11/100,000 to age 25 [DevCan]. zygote / incidence data 62% survival correction Rosenberg et 20/100,000 for cancer of the for tumors other than 145 FA patients: 76 men and 69 women from HPV head neck (or EBV al 2003 [23] RR=333.3 (139.2 -776.2) 6 at mean age 28 oral cavity and pharynx to age liver cancer up to 40 years of cancer incidence data nasopharynx) 35 [DevCan]. 25/1,000,000 at age 30 and 69 women from up to 40 years of cancer Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 HPV vulva RR=2791 (906.7-8033) 3 at mean age 27 9/1,000,000 at age 25 in normal incidence data women [DevCan].

HBV or HCV liver RR=4.06 [1.77 -9.34] 0 carriers; 17 untested 5.68 carriers; 5.03 untested. 11,847 individuals in 699 families, 18.9% Non-carrier RR set to 1.0. (2245) were tested BRCA1 mutation carriers, RR=3.84 [2.33 - 6.33] women Paranasal sinus cancer BRCA1 HPV cervix 8 carriers; 28 untested 2.86 carriers; 11.82 untested 9.3% (1106) were tested non-carriers, and < age 65 among 65 “other cancers” heterozygote / 71.7% (8496) were untested. Cohort included O/E = 12/2.21 carriers; Thompson et HPV (or EBV) Buccal RR= 0.15 (0.06 to 0.40) RR women diagnosed with breast cancer at 53/11.54 untested. 13 al 2002 [24] / cavity, pharynx. (HN- “other” cancers = 7.40 [5.14 - 0 carriers; 16 untested 3.42 carriers; 23.76 untested age<60. Average about 26 yrs follow-up,. Data SCC) 10.66] cases peritoneal cancer as from 30 centers in Europe and N America. “other cancer.” h.pylori stomach RR=1.56 [0.91 - 2.68] 5 carriers; 33 untested 2.58 carriers; 24.80 untested 8

Expected number of No. cancers observed Gene variant Study participants and follow up Infection and cancer cancers as published or Adjustments, com- Effect measure [95% CI] in carriers + possible /Reference method/period target calculated using DevCan or ments carriers SEER statistics Non-carrier RR set to 3728 individuals including 50 men. 471 car- HBV or HCV liver RR=4.18 [1.56 -11.23] 2 carriers; 2 untested 0.56 carriers; 1.45 untested BRCA2 1.0. RR =1.89 [1.5-2.3] riers; 390 non-carriers; 2186 untested. 596 heterozy- all non-breast/ovarian female breast cancer patients diagnosed HPV cervix RR= 1.29 (0.48 - 3.43) 2 carriers; 10 untested 3.73 carriers; 7.42 untested gotes / Breast cancers. 0-<65y. “Other” under age 60. Follow up began on later of Cancer Linkage HPV buccal cavity & includes 2 nose cancers 01/01/1960 or birth until first cancer, death RR=2.26 [1.09 - 4.58] p=0.06 4 carriers; 8 untested 2.26 carriers; 5.47 untested Consortium pharynx (head neck) and several other sites O/ or drop out, age 85 or 12/31/1995. Data 1999 [25] E= 4/1.59 carriers; 9/ 3.39 from 20 centers in W. Europe and N. America. h. pylori stomach RR=2.59 [1.46 -4.61] 8 carriers; 14 untested 3.29 carriers; 8.52 untested untested. HBV or HCV Liver, + SMR=5.00 (0.88 - 28.31) 6 for bile duct and gall- All infection/inflamma- 27 A-T families from North America and bile duct + gallbladder SMR=7.63 (1.24-46.9) for 1 1.2. bladder, 1 primary liver tion associated cancers ATM heterozy- Europe including 1639 individuals In period (1 category until 1965) primary liver age 36 caused at least one death gotes / Swift et 01/01/1930 to 12/31/1973 death certificates 8 with >=1 death at age 322/100,000 age 50 [DevCan]. in people under age 45. al 1976 [31] and hospitalization records were collected to HPV cervix RR= 3.03 (1.54 - 5.95) < 45. 6/8 alive Normal peak age = 47. Other cancers did not. account for deceased relatives. [31] h.pylori stomach SMR=2.00 (0.72 -5.58) 10 (deaths) 5

2785 women from Thames cancer registry: BRCA1/2 HBV or HCV liver RR=1.84 (.05 -10.3) 1 0.54 primary cancer following 2 breast-, 2 ovarian- Low cervical cancer inci- heterozygotes/ or 1 breast- 1 ovarian- cancer. Diagnoses HPV oropharynx RR=14.7 (1.73 -51.6) 2 0.14 dence but high incidence Evans et al before 01/01/1971 followed to 12/31/1982 of uterine cancer. 2001 [29] Later diagnoses to 12/31/1996 h. pylori stomach RR=1.53 (0.62 -3.16) 7 4.56

677 men diagnosed with breast cancer at HBV or HCV liver RR=0.3 (0.0 - 2.53) 0 ( 0.01 in meta-analyses) 0.83 [DevCan] Risk depended on follow- BRCA2 age<56 pooled from 13 cancer registries. up period and age. At 1-9 heterozygotes Followed after diagnosis for up to 20 - 54 y. HPV (or EBV) oral cav- yrs. follow-up, 6 liver can- / Hemminki et RR=1.94( 0.4 -5.66) 3 0.65 Up to 44% estimated risk with positive family ity pharynx cers found in all groups al. 2005 [28] history of breast/ovarian cancer [32]. h. pylori stomach RR=3.82 (1.54 -7.87) 7 1.83 SIR = 2.95 (1.08-6.41). Unlike BRCA2, both HPV cervix SMR=4.21 (1.15-10.79) 4 0.95 383 male relatives and 345 females 87 tumors early family branches of BRCA2 among 728 relatives. Great majority of study BRCA1-cases had been heterozygotes HPV (or EBV) oral cav- groups were young. Living family members SMR=4.17 (0.11 -23.26) 1 0.24 excluded by the authors / Johannsson et ity (head neck) followed from 01/01/1958 in cancer registries [30]. Authors excluded 1 al 1999 [30] until at least 12/31/1995 stomach cancer as a third h.pylori stomach SMR=1.63 [0.34-4.75] 3 (4) 1.84 tumor [30]. 1445 blood relatives of 75 patients with veri- HBV or HCV liver RR=2.7 [1.37-5.44] 8 2.94 [SEER] Mutation detection is ATM heterozy- fied A-T in 66 Nordic families. Most breast problematic for ATM gotes / Olsen cancers at age<55. 712 women and 733 men. HPV cervix RR=3.1 (1.42- 6.82) 6 1.92 [SEER] Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 because of the large size et al 2005 [27] Mean observation = 31.8 years, both sexes 3.67 [SEER]; 2.93 to age 65; 6 h.pylori stomach RR = 4.62 (2.86-7.51) 17 of the gene. and 32.15 yrs. women. to age 75 [DevCan] Obligate RR=4.55 [0.06 - 25.3]; 50% heterozygotes 1 Obligate Obligate heterozygotes 0.22; HBV or HCV liver Cervical cancer was ATM heterozy- 34 families including 1423 relatives of A-T RR=7.69 [1.55 - 22.5] 25% 3 50% heterozygotes 50% heterozygotes: 0.39 reported only as uterine gotes / patients. 715 males and 708 females Obligate RR=7.69[0.86,27.80] cancer (cervix plus Geoffrey-Perez or potential ATM mutation carriers. Data en- Obligate RR=1.61 [0.02 -8.97]; 1 Obligate Obligate heterozygotes 0.62; corpus). Head and neck et al 2001 [26] compass birth to mean age 40-45 at interview. 50% heterozygotes RR= h.pylori stomach 3 50% heterozygotes 50% heterozygotes: 1.35. cancer was not reported. 2.22 [0.45-6.49] 25% RR= 0 25% heterozygotes 25% heterozygotes 0.91 0.011[.000028 -4.5] Relative Risk Homozygotes Relative Risk Heterozygotes 9

Thompson et al [24] 4.06 (1.77, 9.34) 574.1 (233.0, 1414) Alter [21] Breast cancer consortium [25] 4.18 (1.55, 11.23) Liver Obligate carriers 4.55 (.06, 25.30) Geo rey-Perez et al [26] 7.69 (1.55, 22.50) Kutler et al [22] 477.5 (184.2, 1236) 50% carriers 25% carriers 7.69 (0.86, 27.80) Liver Olsen et al [27] 2.70 (1.37, 5.44) Rosenberg et al [23] 275.9 (61.89, 1215) Hemminki et al [28] 0.30 (0.01, 2.53) Evans et al [29] 1.84 (0.05, 10.30) Combined 5.00 (0.88, 28.31) 478.6 (255.9, 895.2) Swift et al [31] 1 3.67 (2.45, 5.48) 10 100 1000 100,000 0.1 0.2 0.5 1 2 5 10 100

Thompson et al [24] 3.84 (2.33, 6.33) Alter [21] 76.61 Johannsson et al [30] 4.21 (1.15, 10.79) Cervix (23.04, 253.1) Kutler et al [22] 239.2 Cervix Swift et al [31] 3.03 (1.54 - 5.95) (92.16, 615.6) Olsen et al [27] 3.1 (1.42, 6.82) Rosenberg 422.8 Breast cancer consortium [25] 1.29 (0.48, 3.43) et al [23] (105.9, 1597) 3.15 (2.27 - 4.35) 1 193.5 (74.81, 500.7) 0.2 0.5 1 2 5 10

10 100 1000 Thompson et al [24] 1.56 (0.91, 2.68)

Breast cancer consortium [25] 2.59 (1.46, 4.61) Vulva Alter [21] 1124 (550.3, 2279) Swift et al [31] 2.00 (0.72, 5.58) 1404 Evans et al [29] Kutler et al [22] Stomach 1.53 (0.62, 3.16) (649, 3001) Hemminki et al [28] 3.82 (1.54, 7.87) Rosenberg et al [23] 2791 (906.7, 8033) Olsen et al [27] 4.62 (2.85, 7.51) Obligate carriers 1433 Geo rey- 1.61 (0.02, 8.97) Combined 50% carriers 2.22 (0.45, 6.49) (882.9, 2326) Perez 25% carriers 0.011 (0.000029, 4.3) 1 et al [26] 10 100 1000 100,000 Johannsson et al [30] 1.63 (0.34, 4.75) 2.38 (1.64, 3.45)

0.1 0.5 1 2 5 10

HNSCC Alter [21] 162.7 (91.83, 287.7) oropharyngeal cancer HNSCC Evans et al [29] 14.30 (1.73, 51.60) Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 Kutler et al [22,37] 203.4 (110.1, 374.3) Breast cancer consortium [25] 2.26 (1.09, 4.58)

Rosenberg et al [23] 333.3 (139.2, 776.2) Hemminki et al [28] 1.94 (0.40, 5.66) 4.17 (0.11, 23.26) Johannsson et al [30] 202.2 (138.0, 296.4) 0.15 (0.06, 0.40) Thompson et al [24] 1 1.84 (0.39, 8.62)

10 100 1000 100,000 0.01 0.1 0.2 1 2 5 10 100

Higher risk Lower risk Higher risk

Fig 3. Forest plots of RRs for infection/inflammation related cancers in carriers of any testable mutation in the model subroutine in Fig.1 containing BRCA1 and BRCA2. RRs for homozygous FA patients are shown in the left column and RRs for heterozygous mutation carriers in the right. 95% confidence intervals are in parentheses after the RR value. A subgroup of HNSCC defined as cancer of the buccal cavity and pharynx or oral cavity gives RR=2.26 [1.22- 4.17] with 0% inconsistency. The results suggest RR and heterogeneity for HNSCC results are partly related to how HNSCC was defined (see text). 10

cers with well-known associations with chronic infection/inflammation – cancer of the liver, cervix, vulva, head and neck area, and stomach. Figure 3 presents this data as graphical forest plots. Table 2 summarizes meta-analyses results and includes age of onset data. Summaries in Table 2 represent 2200 FA homozygotes, and 24, 272 “heterozygotes” as 19,765 BRCA1/2 heterozygotes or potential heterozygotes and 4507 A-T heterozygotes or potential heterozygotes. Risks increase hundreds of times for homozygotes and up to several times for heterozygotes. Thus an infection known to cause chronic inflammation in a specific organ is more likely to lead to cancer in that organ if an inherited mutation is present. Onset of cancers associated with inflammation generally occurs earlier than in control populations (Table 2, column 3). There is enough data available to make results robust so that changing individual study inclusions or exclusions causes only small differences in the combined meta-analysis RR values. The conclusions here were not due to differences in study methodologies or to which gene mutated. Data in Tables 1 and 2 and graphs in Fig. 3 give evidence that RR values do not depend on whether a mutation occurs in a different pathway component such as ATM vs. BRCA1/2 and that there are no obvious systematic errors. For example, in blood relatives of A-T patients, cancers associated with infection or inflammation all caused at least one death at age <45 [31].

Heterogeneity. Even though included studies used somewhat different methodologies, heterogeneity was usually zero or very low except for stomach cancer (I2= 42%, moderate inconsistency). Subgroup analysis suggested RR values and inconsistency in head and neck cancer studies (87.1%) may partly depend on differences in defining head and neck cancers. Three studies reported HNSCC as cancer of the “buccal cavity and/or pharynx or oral cavity”. A subgroup of these three studies gives a summary RR=2.26 [1.22- 4.17] with 0% inconsistency. However, HPV is most clearly associated with oropharyngeal cancer (63% in the US), arising predominantly from the lingual and palatine tonsils. The one study [29] that specifically reported oropharyngeal cancer also found the

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 highest RR.

Limitations. Limitations of these results include comparatively small sample sizes because of the rarity of hereditary diseases. Homozygous FA is especially rare so data originates from three studies involving about 2200 patients. These studies were conducted before some FA proteins were known. It was therefore necessary to consider FA proteins as a group. This is justified biologically based on their interactions (See footnote to Figure 1). The combined RR values for heterozygotes (Table 2) do not represent pure populations of heterozygotes. No study tested every member of a cohort for a mutation. Cohorts in some studies were not typed but were eligible for mutation testing based on personal or strong family histories.

Meta-analyses results agree with independent evidence. The first independent sup- 11

Table 2 Meta-analyses of cancer risks linked to chronic inflammatory infections at specific organ targets in cohorts with mutations in the pathway containing BRCA1 and BRCA2 gene products

Gene(s) and Median age pa- Number of Cumulative inci- number of tients vs. median Summary relative studies in dence in control patients Organ age general pop- risk, 95% confidence meta-analysis patients, patient included in target ulation or other interval and p value or study arms age and from Dev- meta-anal- comparison [reference] Can and/or SEER yses 478.6 (255.9, 895.2) 5 per 100,000 cumu- Liver 13 vs. 66-67 p<0.0001 3 studies includ- lative to age 15-20 ing one with 11 per 100,000 193.5 (74.81, 500.7) summaries of 2200 FA gene Cervix 25 vs. 47 women cumulative P<0.0001 80 years of data homozygotes, to age 25 from the litera- including 1010 25 per 1,000,000 1433 (882.9, 2326) ture and another females Vulva 27 vs. 72 women cumulative p<0.0001 with 20 years of observation [21- to age 30 Head 202.2 (138.0, 296.4) 23, 37] 20 per 100,000 cu- 28 to 33 vs. 74 neck p<0.0001 mulative to age 35 6 liver - biliary system cancers in 907 3.67 (2.45, 5.48) 8 studies / study Liver members of ATM p<0.0001 arms [24-29, 31] families, some fatal before age 45[31] 2 cervical cancers 5 studies / study in 454 ATM females 3.15 (2.27,4.35) 24, 272 Cervix arms [24,25, fatal before age 45 p=.0016 heterozygotes 27,30, 31] [31] as19,765 Country specific Before age 56 BRCA1/2 cancer rates as ex- Stom- (BRCA2 carri- 2.38 (1.64, 3.45) 9 studies / study heterozygotes tracted from original ach ers) vs. age 71 in p<0.0001 arms [24-31] or potential publications, with heterozygotes controls

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 DevCan and SEER and 4507 ATM data both as neces- heterozygotes sary and for compa- or potential 2.26 (1.22, 4.71) rision heterozygotes Half of head and p=0.0093 for subgroup neck cancer pa- with 0% inconsistency) 5 studies / study tients with reduced Head arms [24,25, 28- or absent ATM 1.84 (0.39, 8.62) p=0.44 neck 30,] expression were with 87.1% inconsis- younger than 50 tency for all studies of years old. different cancer sites in head and neck. 12

port for the above results was obtained by verifying that lymphocyte infiltration is present in all five organ specific cancers as a sign of chronic inflammation. Search results (Fig. 2) also included independent data supporting results summarized in Table 2. Table 3 lists this independent evidence from 11 publications in addition to those used for statistical summaries. The first paragraph in Table 3 indicates that the pathway containing BRCA1/2 is the preferred method to repair DNA lesions generated by inflammatory products. BRCA-FA dependent homologous recombination is initiated by fork breakage at adducts produced by peroxynitrite derived from macrophages [33]. Peroxynitrite oxidizes guanine in DNA producing an O-acyl-isourea structure that then reacts with proteins such as histones or glycosylases to form DNA protein adducts. The lesions are so bulky that BRCA-FA dependent homologous recombination occurs in preference to nucleotide excision repair [33]. Impaired homologous recombination would thus favor dangerous gene rearrangements if less specific repair methods then operate [11]. There are also many oppor- tunities for interstrand cross-links. Inflammatory products from immune defenses may favor cancer if essential DNA damage response defenses have been weakened because of an inherited mutation [34]. Table 3 gives further examples of completely independent evidence [35-44] showing that a BRCA pathway mutation magnifies cancer risks from chronic inflammation, which then becomes a major factor in determining the organ targeted by cancer.

Ovarian cancers need not originate in the ovary. Table 4 summarizes evidence from 26 studies [45-72] that inflammation targets ovary and breast in mutation carriers. Regardless of mutation status, most ovarian cancer begins in the fimbriae - fingerlike projections terminating the Fallopian tubes where the ovum released from the ovary is collected. Fimbrial cancers are difficult to distinguish from ovarian cancer because of large areas of intimate contact between fimbria and ovary. The fallopian tube cancer designation requires a dominant mass and evidence of an early Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 cancer there. However ovarian tumor bulk may be greater. In the past, ovarian and tubal cancers were grouped and coded together [25]. Tubal ligation protects against ovarian cancer in both mutation carriers and non-mutation carriers (Table 4). Tubal ligation commonly removes sections of tubes between the uterus and fimbria, presumably preventing infection/inflammation from reaching the fimbriae/ovaries. Ovulation itself may also contribute to inflammation by causing oxidative injury to both the ovary and the fimbria. Inhibiting ovulation by oral contraceptives decreases cancer risk (Table 4). At the site of ovum release, leukocyte invasion, release of nitric oxide and inflammatory cytokines, vasodilation, DNA repair, and tissue remodeling (resembling wound healing) all occur [55].

Table 4 also shows other associations between infection / inflammation and fimbrial-ovarian cancer. These include evidence of inflammation in fallopian tubes and in ovaries removed during prophylactic surgeries and ovarian cancer associated with use of perineal talc. Anti-inflammatory NSAIDs reduce ovarian cancer risk in nulliparous women [56]. 13

Table 3 Independent corroboration that mutations in the BRCA1/2 subroutine magnify risks for cancers with known links to infection / inflammation

Homologous recombination repair requiring the BRCA-FA pathway is essential to repair inflammation related DNA-protein adducts in mammalian cells and to repair other inflammation related DNA damage [33 and see text].

Cells with a defective BRCA pathway are unduly susceptible to viral cancers. Transformation of FA fibroblasts by viral SV40 T-Ag occurs readily and is 3 – 50 times more frequent than in normal cells. Correction of the Fanconi defect reduces transformation potential [35]. Activa- tion of FA proteins is an early host cell response to HPV infection. Expression of high risk HPV oncoproteins in Fanconi deficient cells leads to accelerated chromosomal instability [36].

FA patients are highly susceptible to HPV cancer such as vulvar, cervical and anal cancers[21]. 54% of patients who develop these cancers have a history of HPV-associated condylomas [37]. Odds of finding HPV infection in head and neck squamous cell carcinoma in Fanconi anemia are 8.85 (CI=1.90, 54.19) [37]

Hepatitis C viral proteins down regulate FA protein J, (Bach1) a helicase that interacts with BRCA1 (Fig. 1) [38]. The hepatitis C viral protein NS3/4A interacts with ATM altering its properties [39]. Inactivation of BRCA2 is common in hepatocellular carcinoma, a cancer commonly associated with hepatitis viruses [40].

Fancc-deficient mice exhibit enhanced inflammatory response and are hypersensitive to LPS- induced septic shock as a result of hemopoietic suppression. This exacerbated inflammatory phenotype is intrinsic to the hemopoietic system and can be corrected by the re-expression

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 of a wild-type FANCC gene, suggesting a potential role of the FANCC protein in innate im- munity [41]

Some pathway defect is frequently found in cervical cancers (mainly caused by HPVs). A mutated BRCA1 gene was detected in 13/17 precancerous lesions of the cervix [42]. 42% (34 of 81) of cervical cancers had an allelic imbalance at a locus in 11q23.1 (near or including the ATM gene) [43].

In the Polish population, a family history of ovarian cancer and stomach cancer is associated with germ-line BRCA2 mutations [44]. The frequency of the BRCA2 6174del mutation amoung consecutive Jewish patients with stomach cancer is about 5 times higher than in the general population. 14

The presence of intra-epithelial CD8+ T-cells significantly correlates with loss of BRCA1 [58, 55]. This association links inflammation to mechanisms of genomic instability [58]. Infiltration of ovarian cancers by T-cells may be inflammation marking ovaries for cancer as it does in other organs, even predisposing to loss of BRCA1 [58]. An alternate explanation is that the infiltrate represents an immune response that favors further genomic instability in the tumor. Prophylactic removal of ovaries increases risks for primary peritoneal cancer (Table 4), which occurs in up to 5% of patients. One explanation is that wound healing increases risks for cancer in surrounding tissues. Inflammation is an essential process that occurs early in wound healing.

Breast cancer. T-cell lobulitis is frequently found in morphologically normal breast lobules removed during prophylactic mastectomies [60-61]. The failure to find any premalignant or malignant lesion suggests that there is an immune response before the onset of hereditary breast cancer. T-lymphocyte infiltrates predominate in hereditary breast carcinomas [60-62], unlike diabetic lobulitis where B-cells predominate. In other systems, T-cells produce growth regulatory molecules epidermal growth factor (EGF) and fibroblast growth factor (FGF) which are both implicated in breast cancers. BRCA1 associated breast cancers have more and denser lymphocytic infiltration than sporadic cancers in a matched control group (Table 4). Some extracted infiltrating lymphocyte populations may have tumor killing activity in vitro, suggesting the tumor overcomes such protec- tive functions. A T-lymphocytic infiltrate is also closely associated with medullary breast carcinoma (Table 4), a rare cancer that is more frequent in BRCA1/2 mutation carriers. The medullary cancer infiltrate contains CD4+ and CD8+ T-cells but few tumor killing NK cells [65]. There is a strong signature for an interferon induced pathway in some breast cancer, ovarian cancer and childhood leukemia. This “infection associated gene signature” suggests a deregulated immune or inflammatory response to some pathogen (Table 4). In BRCA1/2 carriers, lymphoid cells

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 are themselves at high risk for becoming malignant [11]. Hematopoietic malignancies would make immune responses in mutation carriers less effective in clearing infection and removing abnormal cells [60, 63]. One candidate source for infection / inflammation in breast cancer are human endogenous retroviruses (HERV). HERV-like sequences are integrated within the human genome. Expression of these sequences can cause inflammatory responses. Strong antibody and T-cell responses to HERV antigens have been found in women with early onset breast cancer and other breast cancer patients (Table 4). Five meta-analyses including up to 91 studies, involving millions of subjects find that NSAIDs protect against breast cancer (Table 4). Breast tissue of women with a background of familial breast cancer have breast fibrosis and less breast differentiation than control or normal tissues [63]. This could result from infection/in- 15

Table 4 Evidence that inflammation targets ovary and breast for hereditary cancers

Cancer Intervention, Evidence of association with inflammation Number of mutation carriers and risks Effect on risk in women with no risk factor, and Effect on risk in mutation carriers if known mutation in the pathway characteristic known. containing BRCA1/2 Depending on cancer detection method and study design, 40-100% of tumors classified as ovarian cancers were fim- Removal of fallo- Contralateral tubes from 14 fallopian tube cancers all brial cancers[46]. 7 consecutive cancers in BRCA+ women Ovarian / pian tubes as can- Risk for fimbrial cancer in normal women is had healed chronic inflammation (p=.0089) suggesting all originated in the fimbrial or ampullary region of the tube Fimbrial cer risk reduction not known. bilateral tubal disease preceding the cancers [45]. [47]. 12/28 (43%) fallopian tube cancers were from women surgery with BRCA mutations. Median age about 8 years < sporadic cases (57 vs. 65) and no exclusively proximal disease [48] In mutation carriers, pooled Odds ratio OR = 0.69 (95% CI = 0.55-0.85). For BRCA1 carriers Hazard 30 publications show an inverse association OR based on a total of 3070 BRCA1 and BRCA2 carriers. Ovarian Tubal ligation ratio, HR=0.49 (0.22-0.80) [49-53] Fallopian tube with ovarian cancer risk based on data from HR from 2,281 BRCA1 and 1,038 BRCA2 carriers [53] cancer originates in distal tube [48, 54] This suggests hundreds of thousands of women. infection/inflammation must travel through the tube. In high-income countries, 10 years OC use Hazard ratio, 0.52; ( 0.37-0.73; P = 0.0002)for BRCA1 reduced incidence at age <75 from 1.2 to 0.8 carriers who had ever used OC. Increasing duration Ovarian Oral contraceptives 2,281 BRCA1 and 1,038 BRCA2 carriers /100 users and mortality from 0.7 to 0.5. ~2 of OC use was associated with a reduced ovarian ovarian cancers and one death at age< 75 are cancer risk (P trend = 0.0004). [53] prevented/5000 woman y. use [55]. Intraepithelial Statistically significant association [58,55] between 11 of 19 cases without BRCA1 abnormalities 17/ 18 cases with BRCA1 mutation or epigenetic silencing tumor infiltrating ovarian cancer and lymphocyte infiltration in BRCA1 (P=0.019) had tumor infiltrating lymphocytes Ovarian of BRCA1 expression had intraepithelial CD8+ tumor- lymphocytes, mac- mutation carriers. This links inflammation to genomic [58]. Macrophages may also be found in infiltrating lymphocytes [58]. rophages instability (see text). ovarian tumors [55]. It is well known that talc causes inflammation in the Use of talc in the pleural cavity. Some talc can contain asbestos fibers. Ovarian Risk in mutation carriers has not been studied. RR as high as 4.8 (2.1-11)[57] perineal region Talc reaches the upper abdominal cavity and is detected in surgically removed ovaries. 487 ovarian cancer cases and 2653 controls. Nulliparous OR=0.47(0.27-0.82) Never users Ovarian Use of NSAIDS Well known anti-inflammatory agents Not separately studied of oral contraceptives OR=0.58 (0.42-0.80) [56] 6/324 women who underwent prophylactic removal Prophylactic sur- of ovaries developed primary peritoneal carcinoma 324 [59]. Also 13 cases of Peritoneal cancer as the most

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 Ovarian gery oophorectomy [59] This may be an example of cancer in surrounding frequent site of “other cancers” in a cohort of BRCA1 in mutation carriers tissues associated with inflammatory processes during women [24] wound healing. 21/41 prophylactic mastectomy specimens. Frequent- Breast inflammation Breast ly found before onset of cancer in high risk women 41 patients who underwent prophylactic mastectomy [60] 21/41 vs 8/82 controls (p < 0.0001) [60]. as lobulitis [60] Breast inflamma- BRCA1/2 mutation carriers have a denser lymphoid 3/52 cancers from women with “no mutation tion as lymphocyte 10/17 with infiltrate varying from mild to dense vs. 13/43 Breast infiltrate in breast cancers compared with their detected” had lymphoid infiltrates vs. 23/157 infiltrate in prophy- cancers in controls without mutation [61] matched, sporadic control group (P= 0.02) [61]. in matched sporadic controls [61]. lactic mastectomies 16

Cancer Intervention, Evidence of association with inflammation Number of mutation carriers and risks Effect on risk in women with no risk factor, and Effect on risk in mutation carriers if known mutation in the pathway characteristic known. containing BRCA1/2 OR=1.90 (1.31-2.76) mild and 2.46(1.26-4.79) prominent, Cancers associated with BRCA1 mutations had higher 219 observations from 114 subjects with mutations in the Lymphocyte infil- mitotic counts (P = .001), and more lymphocytic infil- BRCA1 gene. 141 observations from 73 subjects with Breast trate in BRCA1 See row above and row below tration (P = .002) than sporadic (i.e., control) cancers BRCA2 mutations did not give statistically significant effects. breast cancer [62, 61]. 1046 observations from 528 control subjects with cancers unselected for family history [62] Transitions from normal breast to benign proliferative Large increases in infiltrates in precursor Mononuclear cells breast disease to ductal carcinoma in situ to infiltrat- form benign proliferative breast diseases Breast (T, B-cells, mac- ing ductal carcinomas were associated with signifi- compared to stroma. T-cells 82 vs 4; B-cells rophages) cantly increased mean densities of inflammatory cell 26 vs 3. Smaller increases in DCIS and inva- infiltrates [64] sive diseases [64]. Medullary breast cancer is closely associated with a Intraepithelial dense lymphocyte infiltrate[65] 13/13 cases had a Medullary tumor infiltrating dense T-lymphocyte infiltrate, with few NK cells (see 13 Disease is rare in normal women Breast lymphocytes text). Medullary cancer is more frequent in BRCA1/2 mutation carriers. Genes expressed Data was consistent with BRCA1 positive tumors Breast primarily in lym- having higher lymphocyte infiltrate based on higher 16/18 BRCA1 tumors [66] phocytes expression of lymphocyte specific genes [66]. One explanation is an immune response to viral infection or inflammation [67] Genes important for im- BRCA1 expression is essential to upregulate a group of 40% of 96 breast cancer samples had a strong Interferon regu- Breast munity to infection and for removal of abnormal cells IFN-g regulated genes including an anti-viral protein (8- signature for an interferon induced pathway lated genes are overexpressed in normal parous women but are fold) and an antigen presentation protein (2-fold)[69] [67] not overexpressed in BRCA1 carriers [68] Strong evidence of ongoing immune response in breast cancer patients including antibody, T-cell responses against HERV antigens and gamma interferon BRCA1/2 status was not determined but most breast can- HERV viral protein induction [70]. HERV was reactivated in 88% of breast Breast cers occurred in younger age patients . 26/36 patients were 8 to 25 normal controls [70] expression cancer samples including young women at greater age <=55 and 15/36 age < 50 [70] risk for BRCA1/2 mutations but not in controls [70]. RNA Expression from retrovirus found in high titer in circulating blood from 20 breast cancer patients [71]

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 RR=0.88 (0.84-0.93) based on meta-analysis of 38 studies [72] Five meta-analyses involv- Breast NSAIDS Well-known anti-inflammatory drugs ing millions of subjects and up to 91 studies find that NSAIDs protect against breast cancer. 17 flammation mediated cell and DNA damage or deficiencies in genesequired r for differentiation.

Discussion Hepatitis or human papilloma viruses or h. pylori select specific organs for cancer because their organ targets have specific receptors on the surface of cells. Then transcription factors or other host conditions that permit the infection also influence whether chronic inflammation and then cancer occurs. Not only do genetically related cancers typically occur at young ages but specific cancers associated with viral infections have peak occurrences in younger victims. Viral hepatitis and HPV infections have peak incidences in younger people where risk factors are typically greater and risky behavior is more frequent. The peak age for cervical cancer in women is age 47. Head and neck cancer associated with HPV infection in normal males occurs as cancer of the of the oropharynx and tonsils with peak ages 55-59 [NCI SEER data]. In contrast, many sporadic cancers that are not associated with known infections typically occur at older ages. Inherited defects in a DNA repair subroutine containing BRCA1/2 gene products amplify risks for cancers due to chronic infection or inflammation. This is a mechanism of targeting specific organs for cancer. Molecules that break DNA, including superoxide, hydrogen peroxide, singlet oxygen, and nitrogen oxides are released from activated phagocytic inflammatory cells such as macrophages, monocytes, neutrophils, etc. that are present in tumors. Lymphocytes and other cells are attracted to the site. Many nearby cells are injured or killed. Cellular DNA in this environment is continually damaged and must be repaired or replaced, thereby increasing risks for further dangerous mutations. The cancer targets here include hormone responsive organs in the female reproductive system and the liver where they are metabolized. In a prostate cancer model, hormone receptor complexes move regions of chromosomes into close proximity and increase risks for site specific

Nature Precedings : hdl:10101/npre.2010.4225.1 Posted 18 Feb 2010 cancer related gene fusions after DNA double strand breaks are induced by DNA radiation damage [73]. The pathway containing BRCA1/2 is probably essential to prevent some cancer related gene rearrangements [11]. A repair-deficient genetic background magnifies cancer risks from chronic infection and inflammation, which can then become especially important reasons that a particular organ develops cancer.

Conclusion Mutations in a DNA repair subroutine dependent on BRCA1/2 genes magnify cancer risks from chronic infection and inflammation, making them especially important in selecting the site where hereditary cancer develops. Controlling chronic infections and inflammation may be a helpful option to prevent or delay cancers in mutation carriers. 18

Acknowledgement This work was supported by a grant from the University of Illinois Chicago.

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